Basic Information
| Provider Information | |||||||||
| NPI: | 1144205592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCBENNETT | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20800 HARVARD RD | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | HIGHLAND HILLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441227202 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441061716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168447700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 04/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-082661 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2080P0214X | 35-082661 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 0454744 | 01 | OH | IMCA - MEDICAID GROUP # | OTHER | 2579320 | 05 | OH | MEDICAID | 1821035940 | 01 | OK | AGMC (IMCA) MEDICARE TYPE 2 NPI # | OTHER | 3600271 | 01 | OH | IMCA - MEDICARE GROUP # | OTHER | 1841239274 | 01 | OH | PARTNERS PHYSICIAN GROUP TYPE 2 NPI # | OTHER |